Deborah Dowd, RDH, MS
Idaho State University, 921 South 8th Avenue, Stop 8048, Pocatello, ID, 83209
Authors report no relevant financial disclosures.
Idaho State University, Pocatello, ID
Oral health is vital to promoting good overall health in vulnerable older adults. This study investigated assisted living resident assessments and reassessments of oral health status and the ability to perform oral self-care. Rules and regulations for 12 western states were reviewed. Oral health status was not determined by a clinical examination; residents were asked only limited questions about dentures or chewing and swallowing problems. Activities of daily living (ADL) assessment was mandatory in all 12 states. However, daily oral self-care performance was not always specified as an ADL. ADLs were reassessed at 3 months, 6 months, or annual intervals. Oral health professionals, such as dental hygienists and dentists, should be considered part of the interprofessional team to assess residents’ oral health status and self-care abilities. Improving oral health has the potential to contribute to a resident’s comprehensive health care, well-being, and quality of life.
Key words: oral health, resident assessment instrument, activities of daily living, assisted living, dental hygienists, dentists
Advancing Oral Health in America, a report from the Institute of Medicine (IOM), recognized the need to improve oral health care in the United States.1 One guiding principle was “oral health is an integral part of overall health and, therefore, oral health care is an essential component of comprehensive health care.”1 In addition to systemic links, evidence shows a correlation between poor oral health and quality of life related to eating, speaking, overall appearance, and well-being.2,3
Another IOM report, focused on improving access to oral health care for vulnerable and underserved populations, recognized oral health disparities in the older adult population.4 By 2036, 25% of the US population will be aged 65 years and older. Members of the “baby boomer” generation, born between 1946 and 1964, are now entering their older adult years.5 Soon this generation will be moving into residential care in long-term care (LTC) facilities. Older adults are retaining their natural teeth, thereby increasing the risk for dental caries (decay) and periodontal diseases.5
LTC residents face numerous oral health challenges. Older adults frequently have complex medical histories with multiple health conditions requiring various medications, some with side effects that may reduce salivary flow and cause dry mouth.6,7 Common oral health problems among assisted living (AL) residents include chewing or swallowing difficulties, dry mouth, and oral pain leading to malnutrition.7 Furthermore, residents with memory problems or functional decline of hand dexterity are less likely to brush their teeth daily, and those needing assistance might receive inadequate support.7 Consequently, AL residents have a higher rate of coronal and root caries and an increased occurrence of periodontal diseases and tooth loss.8 Problems with dry mouth, swallowing, and proper oral self-care also increase the risk for aspiration pneumonia.9-13
AL facilities are licensed by states, which establish rules and regulations facilities must follow.14 These requirements include an initial assessment at admission and reassessments at periodic intervals.15 Assessment data are used for planning care and determining needed services.15 However, little is known about state requirements for assessing residents’ oral health status and their ability to perform daily oral self-care.
This descriptive research study investigated the following: (1) what the resident admission assessment processes are for determining oral health status and ability to provide oral self-care in AL facilities; and (2) what the resident reassessment processes are for determining oral health status and ability to provide oral self-care in AL facilities.
This study did not qualify for Institutional Review Board review because no human participants were investigated.
Twelve states in the western region of the United States comprised the sample: (1) Alaska; (2) Arizona; (3) California; (4) Hawaii; (5) Idaho; (6) Montana; (7) Nevada; (8) New Mexico; (9) Oregon; (10) Utah; (11) Washington; and (12) Wyoming. AL state regulations related to the initial assessment and subsequent reassessment of oral health status and oral self-care abilities were accessed. Information was collected about which assessment instruments are used to determine a resident’s oral health status and oral self-care ability, who completes the assessments, when the assessments are completed, and what state department regulates the assessments.
Data collection instruments consisted of tables for recording information to answer the research questions. To demonstrate validity and reliability, a pilot test was conducted by accessing state regulations for Alabama, Connecticut, Indiana, Maine, Minnesota, and Virginia. First, two reviewers completed the data collection together for two states in an effort to standardize the data collection process. Second, each reviewer independently collected data for the four additional states, and these data were compared to determine any necessary changes to the data collection instruments. The pilot study also ensured data were collected in a consistent fashion for each state.
Regulations regarding AL facilities were accessed on the respective state’s department or division of health agency website; laws and statutes were accessed on the state legislature’s website. Using the data collection instruments, the principal investigator completed the initial data collection, and these data were verified by a member of the research team through an independent analysis. When the independent reviews differed, the two investigators collaborated to revisit the rules and regulations to resolve the differences. Verification of the accuracy of the data for each state was completed by a person within the governmental agency responsible for the oversight of AL facilities. Additionally, these contacts answered any remaining questions.
Contacts from 11 of the 12 states responded by email to verify the accuracy of the data. Every state licensed and regulated AL facilities. Licensure required an application to a state department of health and/or social services. State AL regulations are laws; therefore, changes to regulations must pass through the state legislature or assembly.
Definitions of Terms
AL Facility Definition
AL facilities are homelike residential care institutions delivering care to individuals in a safe environment. Table 1 reports the similarities and differences in AL facility definitions and concepts across the states. California focuses on older adults, defining AL as a “residential care facility for the elderly” that provides various levels of care to residents, 75% of whom are aged 60 years or older.16 In comparison, Hawaii and Oregon emphasize the dignity and privacy of AL residents, along with the importance of maintaining their independence.17,18 Montana and Utah classify AL facilities according to the level of care offered.19
Residents in Montana’s Category A facilities need the least amount of care and have a higher level of independence. In comparison, residents in Category B facilities require total assistance with four or more activities of daily living (ADLs), and Category C facilities serve residents with severe cognitive impairment.20 Utah also categorizes AL facilities by level of care. Type I facilities serve individuals who are mobile without assistance and do not require total assistance with more than three ADLs. In comparison, Type II facility residents may have cognitive impairment or physical disabilities and require total assistance from staff in more than three ADLs but can evacuate the facility with limited assistance of one person.21 In general, the level of care is determined by the resident’s ability to perform ADLs, their cognitive status, and their level of independence.
ADLs are daily self-care tasks necessary for an individual’s well-being. Among the 12 states, ADL definitions include eating, bathing, dressing, walking, toileting, mobility, transferring, grooming, and personal hygiene. New Mexico and Utah specifically mention oral hygiene or denture care in their definitions of ADLs.21,22
Personal Care and Service
Personal care services are performed by caregivers without professional skills and include intermittent nursing services, administration of medications, and treatments by a licensed nurse.23 All 12 states provide personal care services to assist residents with ADL. However, personal care regulations in Montana, New Mexico, Oregon, and Washington are specific about providing assistance with daily oral hygiene or denture care or reminding the resident to perform oral care.
Supervisory care services refer to the general supervision of residents to monitor their ability to perform ADLs and their need for assistance.23 The approach to personal and supervisory care services varies among states. Some states’ regulations emphasize the health and safety of residents, whereas other regulations focus on physical well-being and independence. Arizona’s regulations outline another category of services, directed care services, which include supervisory and personal care services provided to residents vulnerable in basic care decision-making, danger recognition, and requests for assistance.23
Facility Scope of Care
AL scope of care outlines specifics related to care provided in the facility. Personal assistance with ADLs is included. However, additional nursing services are included in the scope of care in Alaska, Arizona, California, New Mexico, Utah, and Washington. These services provide intermittent nursing care or higher levels of nursing services when needed. The scope of care for AL facilities in Montana, Utah, Washington, and Wyoming includes arranging for and assisting in health-related services including medical, dental, or optometry care.
Resident Admission Process for Oral Health
State admission assessment rules and regulations, along with state-required oral health assessment tools, were evaluated to answer the first research question regarding the admission assessment process. Findings of the investigation determined that only six states’ regulations address the assessment of oral health status during the resident admission process. However, a resident’s oral health status is determined by asking questions to the resident or family members about having dentures and/or problems associated with chewing and swallowing (Table 2). For instance, California’s physician’s report includes a question about whether the resident has dentures, and Utah’s gastrointestinal system assessment determines whether residents have dentures or removable bridges and problems with chewing or swallowing.24,25 In comparison, Montana’s needs assessment determines only chewing difficulties.26 Lastly, Wyoming’s assessment uses a functional screening question related to resident’s swallowing or choking precautions with eating, and Oregon includes a question about needing assistance to address choking precautions during eating.27,28 The only state to ask about oral or dental status during the resident’s evaluation is New Mexico. No information was found regarding the assessment of oral health status for incoming AL residents in Alaska, Arizona, Hawaii, Idaho, and Nevada.
Article continues after Table 2
None of the states’ admission requirements includes a clinical evaluation of teeth (natural, loose, decayed), gingiva, tongue, lips, saliva flow, or oral cleanliness. Individuals covered by Medicaid are required to have a limited clinical evaluation of their oral status using the Minimum Data Set. This examination includes the condition of dentures; abnormal mouth tissue; inflamed gums; loose, broken, or decayed teeth; oral pain; and chewing difficulties.29 Tooth-brushing ability is evaluated in the ADL section for personal hygiene.29
Only five states’ regulations address the assessment of daily oral care abilities for personal hygiene. This assessment establishes a resident’s functional capabilities and ability to perform ADL self-care in order to determine personal assistance needed and level of care provided. Each state’s department or division of health oversees the requirements for an assessment instrument or criteria for inclusion in the resident assessment.
Montana’s ADL assessment evaluates brushing of teeth as part of the functional assessment of grooming. Another section in this assessment determines dental issues impacting nutritional status.26 Oregon’s client assessment and planning system appraises caring for the mouth in the ADL section related to personal hygiene.28 The ADL assessment in Utah includes the ability to perform oral hygiene and denture care; whereas, oral hygiene ability is assessed in New Mexico.22,25 Washington’s regulations require a full assessment of ADL personal hygiene ability, needs, and preferences, which includes oral care and tooth brushing.30
Another component of the assessment is the recognition of who should conduct it. As Table 2 shows, a variety of individuals are permitted to perform this function, including registered nurses, licensed physicians, physician assistants, advanced practice nurses, or “licensed health care professionals” in general. However, dentists and dental hygienists are not specifically listed as authorized licensed health care professionals designated to conduct these assessments.
Resident Reassessment Process for Oral Health
Regarding the second research question, findings revealed that seven of the 12 states require reassessment of general ADLs at least annually or when there is a significant change in resident health. While all states have an assessment for general ADLs, the only states with information detailed in Table 2 are the ones that specifically acknowledge the assessment of oral health status and/or oral self-care abilities. State regulations in California, Montana, New Mexico, Utah, and Wyoming require reassessment of questions on the states’ assessment forms associated with dentures, chewing, and swallowing on annual or biannual intervals, or upon any significant change in resident condition. In addition, state regulations in Montana, New Mexico, Oregon, Utah, and Washington address the reassessment of oral self-care abilities in caring for the mouth and brushing teeth as part of the ADL every 3 months, 6 months, or annually. No information was found in state regulations for oral health status and self-care assessments or reassessments for Alaska, Arizona, Hawaii, Idaho, and Nevada. The oral health evaluations related to functional ability and ADL performance were the same as for the initial assessment.
This study investigated 12 western states’ rules and regulations related to AL resident admission assessment and reassessment for determining oral health status and ability to provide oral self-care. Findings revealed many inconsistencies between these states and limitations concerning oral health assessments of AL residents.
When residents are admitted to AL facilities, they often present with complex care needs, including medication administration and assistance with multiple ADLs.31 These individuals also present with oral health needs that impact total health. Research has demonstrated that older adults are more vulnerable to oral diseases and conditions such as caries, periodontal diseases, tooth loss, xerostomia, mucosal lesions, and chewing and swallowing difficulties.32,33 These conditions affect quality of life and daily oral care.3,32
Assessment of oral health status lacks consistency and completeness across states. Six of the 12 states include oral-status-related questions or self-care evaluations in the assessment process; however, some assessments are very limited in scope (specifically, in determining oral health status and ability to provide daily self-care). The Swedish Revised Oral Assessment Guide-Jönköping (ROAG-J), a tool developed to evaluate oral health problems and guide decisions about interventions specific to voice, lips, oral mucosa, tongue, gingiva, teeth, saliva, swallowing, and presence of any prosthesis or implants, could serve as a model for oral health assessments in AL facilities in the United States.34
In addition, the findings revealed that several different types of health professionals can conduct oral health assessments; however, none are recognized oral health professionals. Consequently, their ability to appropriately evaluate oral health conditions and treatment needs is questionable. Nordenram and Ljunggren compared dentists’ and nurses’ oral assessments and treatment needs of older adults.35 The researchers found that dentists identified far more oral diseases and treatment needs than nurses, indicating that improvement in nursing training in this area is needed. In general, nurses found the oral assessment of the Resident Assessment Instrument bothersome and used the instrument incorrectly. Another difference was that dentists were properly equipped to perform the examinations using a dental mirror, dental hand instruments, and adequate light. Similarly, Gerritsen et al compared primary care nurses’ and dentists’ oral health evaluation of functional oral health conditions and dental treatment needs of residents.36 In that study, nurses determined that 9% of residents needed treatment, while dentists found 70% of residents required oral health care.36 The authors concluded that nurses do not have the knowledge to ascertain oral problems by intraoral examination. These studies demonstrate the importance of oral health practitioners, who are educated and licensed in their disciplines, conducting oral health assessments and reassessments to provide a realistic picture of residents’ oral health status and ability to engage in oral self-care. Their examinations are based on expertise and conducted with appropriate instruments The inclusion of dental hygienists and dentists on the interprofessional team caring for AL residents has the potential to improve residents’ oral health and, thereby, improve their overall health and quality of life.
This investigation uncovered one controversy related to the different assessments for residents with Medicaid coverage compared with residents with other forms of insurance. Medicaid federal requirements mandate the use of the 3.0 Minimum Data Set for assessment of the resident upon admission. This instrument requires evaluation of oral status on a minimal basis and tooth-brushing ability as an ADL.29 However, all residents admitted to an AL facility regardless of reimbursement method should be assessed for oral health status to determine an appropriate service plan for the integration of oral health into general health and well-being.
One problem residents and their families face is payment for oral health services. The national Medicaid plan does not offer benefits to adults; however, states have the option to include dental benefits for this population.37 Most states provide for emergency dental care, but less than 50% cover comprehensive oral care.37 Medicare does not cover dental services unless a resident is in the hospital and has Medicare Part A.38 Another challenge is identifying oral health providers who accept Medicaid and Medicare. The main reason many do not is lack of adequate reimbursement.39 Given these limitations, dental professionals should work with state health decisionmakers to change policy to include a comprehensive examination by a dental practitioner to determine oral health status and oral care skills during the admission process to LTC facilities. Current payment methods are fee-for-service, but new options for payment are needed to ensure oral health practitioners receive adequate reimbursement for dental services.
This study is not without limitations. The findings were confined to the western region of the United States and, therefore, are not generalizable to the nation. Multiple attempts were made to verify the accuracy of the data by directly contacting each state agency for clarification and obtaining updates to the rules and regulations. However, the data for New Mexico were not verified. Further investigation is needed to determine the impact of including oral health professionals on the interprofessional team to conduct oral status assessments of AL residents. Furthermore, these practitioners should participate in designing assessment instruments to determine oral health status, treatment needs, oral health-related quality of life, and daily oral self-care.
State rules and regulations require AL facilities to conduct resident assessments upon admission and reassessments on a regular basis. This study compared rules and regulations among 12 states in the Western United States for AL resident assessment and reassessment of oral health status and ability to provide self-care. Results revealed assessment for oral health status and oral self-care lacks consistency and completeness across the states. No clinical examinations are performed to assess oral health status, and limited assessments for tooth brushing or denture care are conducted.
Oral health assessments should be conducted by oral health professionals because they have the necessary expertise, licensure, and instruments. Furthermore, oral health professionals should collaborate with state agencies to develop effective assessment instruments to maintain or improve AL residents’ oral health and thereby contribute to their comprehensive health care, well-being, and quality of life.
1. Institute of Medicine. Advancing Oral Health in America. Washington, DC: National Academies Press; 2011.
2. Lindqvist L, Seleskog B, Wårdh I, Bültzingslöwen I. Oral care perspectives of professionals in nursing homes for the elderly. Int J Dent Hyg. 2013;11(4):298-305. doi:10.1111/idh.12016
3. Weening-Verbree L, Waal GH, van Dusseldorp L, van Achterberg T, Schoonhoven L. Oral health care in older people in long term care facilities: a systematic review of implementation strategies. Int J Nurs Stud. 2013;50(4):569-582. doi:10.1016/j.ijnurstu.2012.12.004
4. Institute of Medicine and National Research Council. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Washington, DC: National Academies Press; 2011.
5. McNally ME, Matthews DC, Clovis JB, Brillant M, Filiaggi MJ. The oral health of ageing baby boomers: a comparison of adults aged 45-64 and those 65 years and older. Gerodontology. 2014;31(2):123-135. doi:10.1111/ger.12022
6. Berkey DB, Scannapieco FA. Medical considerations relating to the oral health of older adults. Spec Care Dentist. 2013;33(4):164-176. doi:10.1111/scd.12027
7. Saarela RK, Soini H, Muurinen S, Suominen MH, Pitkala KH. Oral hygiene and associated factors among frail older assisted living residents. Spec Care Dentist. 2013;33(2):56-61. doi:10.1111/j.1754-4505.2012.00314.x
8. Chen X, Clark JJ, Naorungroj S. Oral health in nursing home residents with different cognitive statuses. Gerodontology. 2013;30(1):49-60. doi:10.1111/j.1741-2358.2012.00644.x
9. Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 2005;40(1):1-6.
10. Sarin J, Balasubramaniam R, Corcoran AM, Laudenbach JM, Stoopler ET. Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. J Am Med Dir Assoc. 2008;9(2):128-135. doi:10.1016/j.jamda.2007.10.003
11. Pace CC, McCullough GH. The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations. Dysphagia. 2010;25(4):307-322.
12. Scannapieco FA, Shay S. Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia. Dent Clin North Am. 2014;58(4):771-782. doi:10.1016/j.cden.2014.06.005
13. Ortega O, Sakwinska O, Combremont S, et al. High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia. Neurogastroenterol Motil. 2015;27(12):1804-1816. doi: 10.1111/nmo.12690
14. National Center for Assisted Living. Assisted Living 2017 State Regulatory Review. American Health Care Association; 2017. Accessed December 9, 2019. https://www.ahcancal.org/ncal/advocacy/regs/Documents/2017_reg_review.pdf
15. Carder P, O’Keeffe J, O’Keeffe C. Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition. Office of the Assistant Secretary for Planning and Evaluation; 2015. Accessed April 5, 2018. https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition
16. California Health and Human Services Agency Department of Social Services. Manual of Policies and Procedures, Community Care Licensing Division. Residential Care Facilities for the Elderly (RCFE). State of California; 2018. Title 22, Division 6, Chapter 8. Accessed December 9, 2019. https://www.cdss.ca.gov/Portals/9/Regs/rcfeman1.pdf?ver=2017-05-24-084325-593
17. Hawaii State Department of Health. Hawaii Administrative Rules. State of Hawaii; 1999. Title 11, Chapter 90. Accessed December 9, 2019. http://health.hawaii.gov/opppd/files/2015/06/11-90.pdf
18. Oregon Department of Human Services. Aging and People with Disabilities and Developmental Disabilities — Chapter 411, Division 54, Residential Care and Assisted Living Facilities. State of Oregon; 2018. Accessed March 13, 2020. https://secure.sos.state.or.us/oard/displayDivisionRules.action;JSESSIONID_OARD=EqbUXbmzffnNdWHgvl8rk8yM1tnWOWS3WYWLZV6hMwosSp0M6N4z!-1599462816?selectedDivision=1775
19. National Center for Assisted Living. Assisted living 2018 state regulatory review. American Health Care Association. Accessed December 9, 2019. https://www.ahcancal.org/ncal/advocacy/regs/Documents/2018_reg_review.pdf.
20. Montana Department of Public Health and Human Services. Administrative Rules of Montana, Health Care Facilities. State of Montana; 2004. Subchapter 28, Assisted Living Facilities. Accessed December 9, 2019. https://dphhs.mt.gov/Portals/85/qad/documents/LicensureBureau/HealthCareFacilityLicensing/ALF/subchapter28.pdf
21. Utah Office of Administrative Rules. Utah Administrative Code. Rule State of Utah; 2019. R432-270. Assisted Living Facilities. Accessed December 9, 2019. https://rules.utah.gov/publicat/code/r432/r432-270.htm
22. New Mexico Department of Health. State of New Mexico; 2010. Title 7, Health; Chapter 8, Residential Health Facilities; Part 2, Assisted Living Facilities for Adults. Accessed December 9, 2019. http://126.96.36.199/parts/title07/07.008.0002.html
23. Arizona State Legislature. Arizona Revised Statutes. State of Arizona; 2019. 36-401. Definitions; adult foster care. Accessed December 9, 2019. https://www.azleg.gov/viewdocument/?docName=https://www.azleg.gov/ars/36/00401.htm
24. California Department of Social Services. Physician’s report for residential care facilities for the elderly (RCFE). Accessed December 9, 2019. https://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC602A.pdf
25. Utah Department of Health. Assisted living facility type I & II-resident assessment. Accessed December 9, 2019. http://health.utah.gov/hflcra/forms/ALASSESSMENT.pdf
26. Montana Department of Public Health and Human Services. Assisted living resident needs assessment. Accessed December 9, 2019. https://dphhs.mt.gov/Portals/85/qad/documents/LicensureBureau/HealthCareFacilityLicensing/ALF/ALFResidentNeedsAssessmentRevised_Fillable.pdf
27. Wyoming Department of Health. ()-(8437)_ALF-102. Accessed December 9, 2019. https://health.wyo.gov/aging/hls/forms-and-policies/8437_alf-102/
28. Oregon Department of Human Services. Aging & people with disabilities CA/PS Assessment – updated 5/20/19. Accessed December 9, 2019. http://www.dhs.state.or.us/spd/tools/cm/AssessmentTools/Full%20CAPS%20Assessment%20Paper%20Tool%205-20-19.pdf
29. US Centers for Medicare & Medicaid Services. MDS 3.0 RAI Manual. Accessed December 9, 2019. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
30. Washington State Legislature. Activities of Daily Living. State of Washington; 2018. WAC 388-78A-2190. Accessed December 9, 2019. https://apps.leg.wa.gov/wac/default.aspx?cite=388-78A-2190&pdf=true
31. Han K, Trinkoff AM, Storr CL, Lerner N, Yang BK. Variation across US assisted living facilities: admissions, resident care needs, and staffing. J Nurs Scholarsh. 2017;49(1):23-32. doi:10.1111/jnu.12262
32. Thomson WM. Epidemiology of oral health conditions in older people. Gerodontology. 2014;31(suppl 1):9-16. doi:10.1111/ger.12085
33. Scannapieco FA, Cantos A. Oral inflammation and infection, and chronic medical diseases: implications for the elderly. Periodontol 2000. 2016;72(1):153-175. doi:10.1111/prd.12129
34. Johansson I, Jansson H, Lindmark U. Oral health status of older adults in Sweden receiving elder care: findings from nursing assessments. Nurs Res. 2016;65(3):215-223. doi:10.1097/NNR.0000000000000158
35. Nordenram G, Ljunggren G. Oral status, cognitive and functional capacity versus oral treatment need in nursing home residents: a comparison between assessments by dental and ward staff. Oral Dis. 2002;8(6):296-302.
36. Gerritsen PFM, Schrijvers AJP, Cune MS, van der Bilt A, de Putter C. Assessment of the oral health condition of nursing home residents by primary care nurses. Spec Care Dentist. 2014;34(6):260-264. doi:10.1111/scd.12064
37. US Centers for Medicare & Medicaid Services. Dental care. Accessed December 9, 2019. https://www.medicaid.gov/medicaid/benefits/dental/index.html
38. US Centers for Medicare & Medicaid Services. Dental services. Accessed December 9, 2019. https://www.medicare.gov/coverage/dental-services
39. Sparling E, Lee JC, Mineo B, Viswanathan B, Cheng M. Oral Health Care Management, Recommendations for Long-Term Care Facilities. Delaware Health and Social Services; 2017. Accessed December 9, 2019. https://www.dhss.delaware.gov/dph/hsm/files/oralhealthcaremanagementreport.pdf
40. Washington State Legislature. On-Going Assessments. State of Washington; 2018. WAC 388-78A-2100. Accessed December 9, 2019. https://app.leg.wa.gov/wac/default.aspx?cite=388-78A-2100&pdf=true
41. Wyoming Department of Health. Wyoming Administrative Rules. State of Wyoming; 2007. Chapter 12: Program Administration of Assisted Living Facilities. Accessed December 9, 2019. https://health.wyo.gov/wp-content/uploads/2016/11/HLS-Rule-Ch-12-Assisted-Living-Facilities.pdf